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2022 Plan Guide
ALLINA-HEALTH-AETNA
Below are in-network costs for some of our Medicare benefits. It's not a complete list. For more information about these plans, refer to the Summary of Benefits, visit our website www.AllinaHealthAetnaMedicare.com or call us at 1-833-206-8764 (TTY: 711).
Benefits listed are for services Allina Health Aetna Allina Health Aetna Allina Health Aetna Allina Health Aetna Allina Health Aetna
MedicareEagle(PPO)
MedicareElite(PPO)
MedicareGrand(PPO)
MedicarePremier(PPO)
received in-network and per visit MedicarePlus(PPO)
H3219-005
H3219-004 -
H3219-003 -
H3219-002 -
unless otherwise stated H3219-001 -
-
MonthlyPlanPremium:$0 MonthlyPlanPremium:$47 MonthlyPlanPremium:$96 MonthlyPlanPremium:$152 MonthlyPlanPremium:$0
MN-Anoka, Blue Earth, Brown, Carver,
MN-Anoka, Blue Earth, Brown, Carver,
MN-Anoka, Blue Earth, Brown, Carver,
MN-Anoka, Blue Earth, Brown, Carver,
Service area MN-Anoka, Blue Earth, Brown, Carver,
Chisago, Dakota, Hennepin, Isanti,
Chisago, Dakota, Hennepin, Isanti,
Chisago, Dakota, Hennepin, Isanti,
Chisago, Dakota, Hennepin, Isanti,
Chisago, Dakota, Hennepin, Isanti,
Kanabec, Le Sueur, Kanabec, Le Sueur, Kanabec, Le Sueur, Kanabec, Le Sueur, Kanabec, Le Sueur,
McLeod, Meeker, Nicollet, Ramsey,
McLeod, Meeker, Nicollet, Ramsey,
McLeod, Meeker, Nicollet, Ramsey,
McLeod, Meeker, Nicollet, Ramsey,
McLeod, Meeker, Nicollet, Ramsey,
Renville, Scott, Sibley, Steele, Waseca,
Renville, Scott, Sibley, Steele, Waseca,
Renville, Scott, Sibley, Steele, Waseca,
Renville, Scott, Sibley, Steele, Waseca,
Renville, Scott, Sibley, Steele, Waseca,
Washington, Wright
Washington, Wright
Washington, Wright
Washington, Wright
Washington, Wright
Part B premium reduction $0 $0 $0 $0 $20
Plan deductible $0 $0 $0 $0 $0
Annual maximum out-of-pocket $5,900 for in-network services. $3,800 for in-network services. $3,100 for in-network services. $2,800 for in-network services. $5,900 for in-network services.
amount (does not include premium or $10,000 for in- and out-of $6,000 for in- and out-of $5,150 for in- and out-of $4,000 for in- and out-of $10,000 for in- and out-of
prescription drugs) network services combined. network services combined. network services combined. network services combined. network services combined.
Hospital coverage
Inpatient hospital coverage $350 per day, days 1-5; $500 per stay $200 per stay $150 per stay $350 per day, days 1-5;
Plan covers unlimited hospital days. Plan covers unlimited hospital days. Plan covers unlimited hospital days. $0 per day, days 6-90
$0 per day, days 6-90
$0 copay for additional days. $0 copay for additional days.
Plan covers unlimited hospital days. Plan covers unlimited hospital days.
Outpatient hospital $400 $300 $200 $100 $400
Ambulatory surgery center $350 $250 $150 $50 $350
(ASC)
Skilled nursing facility $0 per day, days 1-20; $0 per day, days 1-20; $0 per day, days 1-20; $0 per day, days 1-20; $0 per day, days 1-20;
$188 per day, days 21-100 $188 per day, days 21-100 $188 per day, days 21-100 $188 per day, days 21-100 $188 per day, days 21-100
Our plan covers up to 100 Our plan covers up to 100 Our plan covers up to 100 Our plan covers up to 100 Our plan covers up to 100
days per benefit period. days per benefit period. days per benefit period. days per benefit period. days per benefit period.
Doctor visits
Primary care provider (PCP) $0 $0 $0 $0 $0
PCP referrals required This plan doesn't require a referral to This plan doesn't require a referral to This plan doesn't require a referral to This plan doesn't require a referral to This plan doesn't require a referral to
see a specialist, but the specialist may see a specialist, but the specialist may see a specialist, but the specialist may see a specialist, but the specialist may see a specialist, but the specialist may
require one from your PCP. require one from your PCP. require one from your PCP. require one from your PCP. require one from your PCP.
1 PG22-MN01-ALLINA-HEALTH-AETNA
Benefits listed are for services Allina Health Aetna Allina Health Aetna Allina Health Aetna Allina Health Aetna Allina Health Aetna
MedicareEagle(PPO)
received in-network and per visit MedicarePlus(PPO) MedicarePremier(PPO) MedicareGrand(PPO) MedicareElite(PPO)
unless otherwise stated H3219--001 H3219--002 H3219--003 H3219--004 H3219--005
MonthlyPlanPremium:$0 MonthlyPlanPremium:$47 MonthlyPlanPremium:$96 MonthlyPlanPremium:$152 MonthlyPlanPremium:$0
Specialist $40 $25 $20 $15 $40
Outpatient mental health therapy $40 $25 $20 $15 $40
(individual)
Emergency and urgent care
Emergency room $90 $90 $90 $90 $90
Urgent care facility $0 - $40 $0 - $25 $0 - $20 $0 - $15 $0 - $40
Lower cost sharing is for services Lower cost sharing is for services Lower cost sharing is for services Lower cost sharing is for services Lower cost sharing is for services
provided by your primary provided by your primary provided by your primary provided by your primary provided by your primary
care physician in their office. care physician in their office. care physician in their office. care physician in their office. care physician in their office.
Worldwide coverage (i.e., outside of the $90 for emergency and $90 for emergency and $90 for emergency and $90 for emergency and $90 for emergency and
United States) urgent care worldwide. urgent care worldwide. urgent care worldwide. urgent care worldwide. urgent care worldwide.
Diagnostic testing
X-rays and diagnostic radiology X-rays: $45 X-rays: $30 X-rays: $20 X-rays: $0 X-rays: $45
Diagnostic radiology: $200 Diagnostic radiology: $150 Diagnostic radiology: $100 Diagnostic radiology: $50 Diagnostic radiology: $200
Lab services $0 $0 $0 $0 $0
Dental, vision and hearing (Non-Medicare covered)
Dental services $675 maximum benefit in- $800 maximum benefit in- $1,500 maximum benefit in- $2,250 maximum benefit in- $2,250 maximum benefit in-
and out-of-network every and out-of-network every and out-of-network every year and out-of-network every year and out-of-network every year
year for preventive and year for preventive and for preventive and for preventive and for preventive and
comprehensive dental combined. comprehensive dental combined. comprehensive dental combined. comprehensive dental combined. comprehensive dental combined.
Aetna Dental® PPO Network Aetna Dental® PPO Network Aetna Dental® PPO Network Aetna Dental® PPO Network Aetna Dental® PPO Network
Routine eye exam $0 (one exam every year) $0 (one exam every year) $0 (one exam every year) $0 (one exam every year) $0 (one exam every year)
Eyewear $200 reimbursement** every year. $250 reimbursement** every year. $275 reimbursement** every year. $350 reimbursement** every year. $350 reimbursement** every year.
You can see any licensed provider. You can see any licensed provider. You can see any licensed provider. You can see any licensed provider. You can see any licensed provider.
Discounts may be available when Discounts may be available when Discounts may be available when Discounts may be available when Discounts may be available when
seeing an EyeMed provider. seeing an EyeMed provider. seeing an EyeMed provider. seeing an EyeMed provider. seeing an EyeMed provider.
Routine hearing exam $0 (one exam every year) $0 (one exam every year) $0 (one exam every year) $0 (one exam every year) $0 (one exam every year)
All appointments should be scheduled All appointments should be scheduled All appointments should be scheduled All appointments should be scheduled All appointments should be scheduled
through NationsHearing or participating through NationsHearing or participating through NationsHearing or participating through NationsHearing or participating through NationsHearing or participating
network provider. network provider. network provider. network provider. network provider.
2 PG22-MN01-ALLINA-HEALTH-AETNA
Benefits listed are for services Allina Health Aetna Allina Health Aetna Allina Health Aetna Allina Health Aetna Allina Health Aetna
MedicareEagle(PPO)
received in-network and per visit MedicarePlus(PPO) MedicarePremier(PPO) MedicareGrand(PPO) MedicareElite(PPO)
unless otherwise stated H3219--001 H3219--002 H3219--003 H3219--004 H3219--005
MonthlyPlanPremium:$0 MonthlyPlanPremium:$47 MonthlyPlanPremium:$96 MonthlyPlanPremium:$152 MonthlyPlanPremium:$0
Hearing aids $500 (per ear) maximum $750 (per ear) maximum $1,000 (per ear) maximum $2,000 (per ear) maximum $1,000 (per ear) maximum
benefit every year. benefit every year. benefit every year. benefit every year. benefit every year.
All hearing aids should be purchased All hearing aids should be purchased All hearing aids should be purchased All hearing aids should be purchased All hearing aids should be purchased
through NationsHearing. through NationsHearing. through NationsHearing. through NationsHearing. through NationsHearing.
**Member pays the provider upfront and we pay the member back. Plan coverage rules apply.
Therapy
Physical and speech therapy $40 $25 $20 $15 $40
Occupational therapy $40 $25 $20 $15 $40
Ambulance
Ground ambulance (one-way trip) $305 $315 $250 $250 $300
Air ambulance (one-way trip) $305 $315 $250 $250 $300
Equipment and prosthetics
Durable medical equipment 20% 20% 20% 20% 20%
Prosthetics 20% 20% 20% 20% 20%
Additional benefits Allina Health Aetna Allina Health Aetna Allina Health Aetna Allina Health Aetna Allina Health Aetna
MedicarePlus(PPO) MedicarePremier(PPO) MedicareGrand(PPO) MedicareElite(PPO) MedicareEagle(PPO)
H3219--001 H3219--002 H3219--003 H3219--004 H3219--005
MonthlyPlanPremium:$0 MonthlyPlanPremium:$47 MonthlyPlanPremium:$96 MonthlyPlanPremium:$152 MonthlyPlanPremium:$0
24-Hour Nurse Line $0 $0 $0 $0 $0
Speak with a registered nurse Speak with a registered nurse Speak with a registered nurse Speak with a registered nurse Speak with a registered nurse
24 hours a day, 7 days a week to
24 hours a day, 7 days a week to
24 hours a day, 7 days a week to
24 hours a day, 7 days a week to
24 hours a day, 7 days a week to
discuss medical issues or
discuss medical issues or
discuss medical issues or
discuss medical issues or
discuss medical issues or
wellness topics. wellness topics. wellness topics. wellness topics. wellness topics.
Acupuncture services (additional) $20 (up to eighteen $20 (up to eighteen $20 (up to eighteen $20 (up to eighteen $20 (up to eighteen
visits every year) visits every year) visits every year) visits every year) visits every year)
Allina Health | Aetna Medicare $100 every three months Not covered Not covered Not covered Not covered
Payment Card You'll receive an Allina Health
| Aetna Medicare Payment
Card that you can use toward
in-network copays, if
applicable, for PCP, specialist, and
certain other services.
3 PG22-MN01-ALLINA-HEALTH-AETNA
Additional benefits Allina Health Aetna Allina Health Aetna Allina Health Aetna Allina Health Aetna Allina Health Aetna
MedicarePlus(PPO) MedicarePremier(PPO) MedicareGrand(PPO) MedicareElite(PPO) MedicareEagle(PPO)
H3219--001 H3219--002 H3219--003 H3219--004 H3219--005
MonthlyPlanPremium:$0 MonthlyPlanPremium:$47 MonthlyPlanPremium:$96 MonthlyPlanPremium:$152 MonthlyPlanPremium:$0
Chiropractic services (additional) $20 (up to eighteen $20 (up to eighteen $20 (up to eighteen $20 (up to eighteen $20 (up to eighteen
visits every year) visits every year) visits every year) visits every year) visits every year)
Fitness SilverSneakers® SilverSneakers® SilverSneakers® SilverSneakers® SilverSneakers®
All members of the plan are
Healthy Rewards All members of the plan are All members of the plan are All members of the plan are All members of the plan are
eligible to earn gift cards for eligible to earn gift cards for eligible to earn gift cards for eligible to earn gift cards for eligible to earn gift cards for
completing certain health and completing certain health and completing certain health and
completing certain health and completing certain health and
wellness activities.
wellness activities. wellness activities. wellness activities. wellness activities.
Meals Up to 14 home delivered meals Up to 14 home delivered meals Up to 14 home delivered meals Up to 14 home delivered meals Up to 14 home delivered meals
over a 7-day period after being over a 7-day period after being over a 7-day period after being over a 7-day period after being over a 7-day period after being
discharged from an Inpatient discharged from an Inpatient discharged from an Inpatient discharged from an Inpatient discharged from an Inpatient
Acute Hospital, Inpatient Acute Hospital, Inpatient Acute Hospital, Inpatient
Acute Hospital, Inpatient Acute Hospital, Inpatient
Psychiatric Hospital or Skilled
Psychiatric Hospital or Skilled Psychiatric Hospital or Skilled Psychiatric Hospital or Skilled Psychiatric Hospital or Skilled
Nursing Facility to home. Nursing Facility to home. Nursing Facility to home. Nursing Facility to home. Nursing Facility to home.
Over-the-counter items (OTC) $75 maximum benefit every quarter $90 maximum benefit every quarter $105 maximum benefit every $120 maximum benefit every $120 maximum benefit every
through OTC Health Solutions through OTC Health Solutions quarter through OTC Health
quarter through OTC Health quarter through OTC Health
or at participating CVS® stores. or at participating CVS® stores. Solutions or at participating Solutions or at participating Solutions or at participating
CVS® stores. CVS® stores. CVS® stores.
Personal emergency response Not covered Not covered Not covered Members are eligible for an alert Not covered
system system through LifeStation.
Telehealth You can receive primary You can receive primary You can receive primary You can receive primary You can receive primary
care, physician specialist, care, physician specialist, care, physician specialist, care, physician specialist, care, physician specialist,
mental health and urgent care mental health and urgent care mental health and urgent care
mental health and urgent care mental health and urgent care
services through a virtual visit. services through a virtual visit. services through a virtual visit. services through a virtual visit. services through a virtual visit.
Members should contact their Members should contact their Members should contact their Members should contact their Members should contact their
doctor for information on what doctor for information on what doctor for information on what doctor for information on what doctor for information on what
telehealth services they offer and telehealth services they offer and telehealth services they offer and telehealth services they offer and
telehealth services they offer and
how to schedule a telehealth visit. how to schedule a telehealth visit. how to schedule a telehealth visit. how to schedule a telehealth visit. how to schedule a telehealth visit.
Depending on location, Depending on location, Depending on location, Depending on location, Depending on location,
members may also have the option to members may also have the option to members may also have the option to members may also have the option to members may also have the option to
schedule a telehealth visit 24 hours a schedule a telehealth visit 24 hours a schedule a telehealth visit 24 hours a schedule a telehealth visit 24 hours a schedule a telehealth visit 24 hours a
day, 7 days a week via Teladoc, day, 7 days a week via Teladoc, day, 7 days a week via Teladoc, day, 7 days a week via Teladoc, day, 7 days a week via Teladoc,
MinuteClinic Video Visit, or other MinuteClinic Video Visit, or other MinuteClinic Video Visit, or other MinuteClinic Video Visit, or other MinuteClinic Video Visit, or other
provider that offers telehealth services provider that offers telehealth services provider that offers telehealth services provider that offers telehealth services provider that offers telehealth services
covered under your plan. covered under your plan. covered under your plan. covered under your plan. covered under your plan.
Visitor/travel benefit Explorer: Allows you to receive care at Explorer: Allows you to receive care at Explorer: Allows you to receive care at Explorer: Allows you to receive care at Explorer: Allows you to receive care at
in-network cost shares from our
in-network cost shares from our in-network cost shares from our in-network cost shares from our in-network cost shares from our
participating multi-state provider participating multi-state provider participating multi-state provider participating multi-state provider participating multi-state provider
network for up to twelve months when network for up to twelve months when network for up to twelve months when network for up to twelve months when network for up to twelve months when
outside the service area. outside the service area. outside the service area. outside the service area. outside the service area.
4 PG22-MN01-ALLINA-HEALTH-AETNA
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